Browsing by Author "Zuege, Danny J"

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    Association between afterhours admission to the intensive care unit, strained capacity, and mortality: a retrospective cohort study
    (2018-04-17) Hall, Adam M; Stelfox, Henry T; Wang, Xioaming; Chen, Guanmin; Zuege, Danny J; Dodek, Peter; Garland, Allan; Scales, Damon C; Berthiaume, Luc; Zygun, David A; Bagshaw, Sean M
    Abstract Background Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00–06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. Methods This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00–06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. Results Of 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7–37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44–70) vs 60 (47–70) years, p < 0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p < 0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p < 0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p = 0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923–1.135, p = 0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p = 0.90) or hospital length of stay (LOS) (p = 0.27), although ICU LOS was shorter (p = 0.049). Early-morning admission (00:00–06:59 h) with ICU occupancy ≥ 90% was associated with short-term (≤ 7 days) and all-cause ICU mortality. Conclusions One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.
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    Describing organ dysfunction in the intensive care unit: a cohort study of 20,000 patients
    (2019-05-23) Soo, Andrea; Zuege, Danny J; Fick, Gordon H; Niven, Daniel J; Berthiaume, Luc R; Stelfox, Henry T; Doig, Christopher J
    Abstract Background Multiple organ dysfunction is a common cause of morbidity and mortality in intensive care units (ICUs). Original development of the Sequential Organ Failure Assessment (SOFA) score was not to predict outcome, but to describe temporal changes in organ dysfunction in critically ill patients. Organ dysfunction scoring may be a reasonable surrogate outcome in clinical trials but further exploration of the impact of case mix on the temporal sequence of organ dysfunction is required. Our aim was to compare temporal changes in SOFA scores between hospital survivors and non-survivors. Methods We performed a population-based observational retrospective cohort study of critically ill patients admitted from January 1, 2004, to December 31, 2013, to 4 multisystem adult intensive care units (ICUs) in Calgary, Canada. The primary outcome was temporal changes in daily SOFA scores during the first 14 days of ICU admission. SOFA scores were modeled between hospital survivors and non-survivors using generalized estimating equations (GEE) and were also stratified by admission SOFA (≤ 11 versus > 11). Results The cohort consisted of 20,007 patients with at least one SOFA score and was mostly male (58.2%) with a median age of 59 (interquartile range [IQR] 44–72). Median ICU length of stay was 3.5 (IQR 1.7–7.5) days. ICU and hospital mortality were 18.5% and 25.5%, respectively. Temporal change in SOFA scores varied by survival and admission SOFA score in a complicated relationship. Area under the receiver operating characteristic (ROC) curve using admission SOFA as a predictor of hospital mortality was 0.77. The hospital mortality rate was 5.6% for patients with an admission SOFA of 0–2 and 94.4% with an admission SOFA of 20–24. There was an approximately linear increase in hospital mortality for SOFA scores of 3–19 (range 8.7–84.7%). Conclusions Examining the clinical course of organ dysfunction in a large non-selective cohort of patients provides insight into the utility of SOFA. We have demonstrated that hospital outcome is associated with both admission SOFA and the temporal rate of change in SOFA after admission. It is necessary to further explore the impact of additional clinical factors on the clinical course of SOFA with large datasets.
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    Sex-specific prevalence and outcomes of frailty in critically ill patients
    (2020-09-29) Hessey, Erin; Montgomery, Carmel; Zuege, Danny J; Rolfson, Darryl; Stelfox, Henry T; Fiest, Kirsten M; Bagshaw, Sean M
    Abstract Background The prevalence of frailty, an important risk factor for short- and long-term outcomes in hospitalized adults, differs by sex. Studies in critically ill adults have also found differences in mortality and organ support rates in males and females. The objective of this study was to determine if these observed differences in mortality and organ support rates can be explained by sex and frailty alone, or if the interaction between sex and frailty is an important risk factor. Methods This is a retrospective multi-centre population-based cohort study of all adult patients (≥ 18 years) admitted to the seventeen intensive care units (ICUs) across Alberta, Canada, between 2016 and 2017. On admission, physicians assigned a Clinical Frailty Scale (CFS) score (1 = very fit, 9 = terminally ill) to all patients. Patients with missing CFS scores or who died within 24 h of ICU admission were excluded. Frailty was defined as CFS ≥ 5. Outcomes included all-cause hospital mortality, ICU mortality, and organ support rates. A propensity score for female sex was generated and 1:1 matching on sex was performed. Multivariable Cox regression or logistic regression, as appropriate, was performed to evaluate the association between sex, frailty, and the sex-frailty interaction term with outcomes. Results Of 15,238 patients included in the cohort, after propensity score matching 11,816 patients remained (mean [standard deviation] age 57.3 [16.9]). In the matched cohort, females had a higher prevalence of frailty than males (32% vs. 27%, respectively) and higher odds of frailty (odds ratio [95% confidence interval (CI)] 1.29 [1.20–1.40]). Though females were less likely to receive invasive mechanical ventilation (hazard ratio [95% CI] 0.78 [0.71–0.86]), the interaction between sex and frailty (i.e., males and females with and without frailty) was not associated with differences in organ support rates. Receipt of dialysis and vasoactive support, as well as hospital mortality and ICU mortality were associated with frailty but were not associated with female sex or the interaction between sex and frailty. Conclusions Although frailty and sex were individually associated with mortality and differences in organ support in the ICU, there does not appear to be a significant interaction between sex and frailty with regards to these outcomes.